Medicare Blue Choice Platinum (HMO-POS) - Excellus Prospect

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Medicare Blue Choice Platinum (HMO-POS)

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MDC-Medicare Blue Choice Platinum - Plan Features - Even

For Coverage January 1, to December 31,

Plan Features

  • NEW for 2020, add Full Comprehensive Dental coverage to your plan, for an additional $39 a month. This includes coverage for restorative and major dental services (i.e., crowns, root canals). Coverage for preventive dental services (i.e., cleanings and x-rays) is included with your plan.3 (View our Supplemental Dental plans)
  • NEW for 2020, you pay 50% of the cost for up to 10 acupuncture visits.
  • Robust provider network1
  • No referrals required
  • $120 annual eyewear allowance
  • Worldwide urgent care and emergency coverage
  • The Silver&Fit® Fitness Program. $25 annual non-refundable fee for gym membership. Other program options are available. Find a participating fitness center near you.
  • Coverage for hearing aids through our partner TruHearing® (a copayment will apply)

MDC-Medicare Blue Choice Platinum - Benefits - Even

Benefits2

Medical Coverage
Medicare Blue Choice Platinum (HMO-POS) provides comprehensive coverage for the health care services you need, including:

  • Out-of-Network coverage under the point of service benefit: 30% coinsurance; $3,000 annual maximum.
  • $15 copay per visit for an in-network primary care providers
  • $40 copay per visit for in-network specialists
  • $0 copay for many Medicare-covered preventive services in-network, such as physical exams, smoking cessation and some immunizations
  • $15 copay for in-network chiropractic medical visits
  • Inpatient Hospital Stay
    • $260 copay per day for days 1-5 for each Medicare-covered stay at a network hospital
    • Days 6+ covered in full
  • $5,500 annual Out-of-Pocket Maximum Protection (In-network services)

MDC-Medicare Blue Choice Platinum - Learn More - Even

Learn more with these resources:

1 Network Coverage Information - With our Medicare Advantage Health Maintenance Organization (HMO) plans you must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. The Point-of-Service (POS) benefit gives extra flexibility to receive some covered services from providers that are not in our network without having to pay the entire cost yourself. The POS benefit has a coverage limit. Once your costs go above this limit, you will be responsible for 100% of the remaining costs for the out-of-network services. For information on how to request reimbursement for Out-of-Network claims, the Point-of-Service (POS) benefit, Out-of-Network Coverage, or Coverage Determinations and Appeals call Customer Care at 1-877-883-9577, Monday - Friday, 8 a.m. to 8 p.m.; From October 1 through March 31, 8 a.m. to 8 p.m., 7 days a week (TDD/TTY  1-800-662-1220). Or, see the Evidence of Coverage using the link above. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

2 This information is not a complete description of benefits. Call 1-800-671-6081 (TDD/TTY  1-800-662-1220) for more information.

3For out-of-network providers, we will pay 100% of the allowance or dentist charges, whichever is less, You will be responsible for the balance.

To the extent of any discrepancy between this web site and the Evidence of Coverage, the Evidence of Coverage terms take priority.

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Call: 1-800-671-6081
TDD/TTY: 1-800-662-1220

Monday - Friday:
8 a.m. to 8 p.m.

From Oct. 1 - Dec. 30:
advisors are also available weekends 8 a.m. to 8 p.m.

Closed Thanksgiving Day, Christmas Eve, Christmas Day, New Year’s Eve, and New Year’s Day


Call Customer Service toll-free at 1-877-883-9577 (TTY/TDD 1-800-662-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Dec. 31, representatives also are available weekends from 8 a.m. to 8 p.m.

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Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_5993.

This page last updated 10-01-2019.